Avia Banks

Aspire To More Travel, Independent Travel Advisor w/InteleTravel

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		<field type="header" subtype="h1" label="TRAVEL&amp;nbsp; INSURANCE COVERAGE REQUEST FORM"/>&#13;
		<field type="paragraph" subtype="p" label="Unexpected emergencies can arise, and the penalties imposed by cruise lines, airlines, hotels, and tour operators for cancellations can be substantial, ranging from forfeiting full deposits to no refunds at all. It is also crucial to note that in the absence of travel insurance, you may find yourself without coverage in a medical emergency abroad, as domestic health policies typically do not apply outside the United States. Overseas hospitals often require upfront payment, and having travel insurance means a simple call to the 24-hour assistance hotline. We can help.&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="Please provide the following information to enable us to properly assist you with your travel protection needs. Your personal information is treated with care and will only be used for the purpose of assisting you with securing and booking travel related services."/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name" name="middle-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Street Address" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="ABOUT YOUR TRIP"/>&#13;
		<field type="date" required="true" label="Trip Departure Date" name="when-would-you-like-to-depart-" className="form-control"/>&#13;
		<field type="text" required="true" label="Where are you departing from?" name="where-are-you-departing-from" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Destination(s)" name="where-would-you-like-to-go-" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Trip Return Date" name="when-would-you-like-to-return-" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of First Deposit (When did you purchase the first travel service you want coverage for?)" name="date-of-first-deposit-when-did-you-purchase-the-first-travel-service-you-want-coverage-for" className="form-control"/>&#13;
		<field type="textarea" label="Who will be traveling? Please list all full names and birthdays&amp;nbsp;" name="who-will-be-traveling-please-list-all-full-names-including-middle-and-birthdays-" className="form-control"/>&#13;
		<field type="checkbox-group" label="What&amp;nbsp; non-refundable&amp;nbsp; travel components would you like travel protection coverage for? Check all that apply.&amp;nbsp;" name="what-travel-components-would-you-like-us-to-assist-you-with-check-all-that-apply-" other="true">&#13;
			<option label="Flights" value="flights">Flights</option>&#13;
			<option label="Accommodations" value="accommodations">Accommodations</option>&#13;
			<option label="Transportation (car rental, trains, etc.)" value="transportation-car-rental-trains-etc">Transportation (car rental, trains, etc.)</option>&#13;
			<option label="Cruise" value="cruise">Cruise</option>&#13;
			<option label="Excursions &amp; tours" value="excursions-tours">Excursions &amp; tours</option>&#13;
		</field>&#13;
		<field type="textarea" required="true" label="What service providers&amp;nbsp; were used for your trip?" description="i.e. American Airlines  Delta Airlines  Carnival  Marriott  Sandals  GoWay Travel  Apple Vacations  etc." name="what-service-providers-did-you-use-for-your-trip" className="form-control"/>&#13;
		<field type="text" required="true" label="What is the total cost of the travel services for this trip?" name="what-is-the-total-cost-of-the-travel-services-for-this-trip" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What coverage plan would you like to purchase?" name="what-is-your-budget-for-all-travelers-this-just-gives-me-a-general-starting-point-and-can-always-be-changed-later-" other="true">&#13;
			<option label="Allianz Basic Plan" value="allianz-basic-plan">Allianz Basic Plan</option>&#13;
			<option label="Allianz Classic Plan" value="allianz-classic-plan">Allianz Classic Plan</option>&#13;
			<option label="Allianz Classic Plan Cancel for Any Reason" value="allianz-classic-plan-cancel-for-any-reason">Allianz Classic Plan Cancel for Any Reason</option>&#13;
			<option label="Allianz Premier Plan" value="allianz-premier-plan">Allianz Premier Plan</option>&#13;
			<option label="Allianz Group Advantage  Plan (10 or more travelers)" value="allianz-group-advantage-plan-10-or-more-travelers">Allianz Group Advantage  Plan (10 or more travelers)</option>&#13;
			<option label="I'm not sure. Provide a comparison quote." value="im-not-sure-provide-a-comparison-quote">I'm not sure. Provide a comparison quote.</option>&#13;
		</field>&#13;
		<field type="text" label="Who can we thank for referring you to us?&amp;nbsp;" name="who-can-we-thank-for-referring-you-to-us-" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
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